Survey- Veterans/Active Military & Dependents with Hepatitis C

This information will help determine "clusters" of patients with hepatitis C infected by the same transmission method. Compare your history for the ID number
of all GIs stationed with or near you at one point in time during your military service. Results will post as soon as the form is submitted. Personal information including email address will not be posted.  If you changed service or re-enlisted please enter a separate record for each enlistment. View Survey Results

When filling out this form, do not hit the enter key until you are finished. Use the tab key  (top left of keyboard)  to move between the fields. The enter key will submit the form before you are finished. If that does happen, use the back button on the browser and continue where you left off. Use the submit button or enter key when the form is completed

Please enter:
E-mail 
Name
First   Last
Check this box if updating  information all ready
submitted to the Database 

Please select:  Branch of Service 

Dates of service :  
Enlistment date:
 
Discharged date:
  
 

Do you have Hepatitis C? Yes No
If Yes, Please enter your Genotype (1, 1a, 1b, 2a, 2b, 3a etc)
Genotype is the genetic code of what type of Hepatitis C you have.
There are several different types. If you do not know, please find out and update your info.
 Genotype 

Do you or did you have Hepatitis B? Yes No

Transmission Methods
Did you receive an immune globulin shot?  
This shot was given to soldiers exposed to outbreaks of Hepatitis A & B. Immune globulin is also used in the smallpox vaccinia shot given in case of reaction to the smallpox vaccine.

Check any and all methods you may have been
exposed to the hepatitis C virus during military service.  
Jet "Air Gun" Injections Used Razors (and dry shaving) Medical/ Dental (no gloves used) 
Reused Syringes & Vials Barber Electric Razors Medical Surgery
Finger pricks with Lancets   Barber Straight Edge     Dental Surgery
Contaminated Vaccine/ Lyophilized  vaccines, Immune Serum Globulin (ISG) Exposed to Blood/body fluid Share Nail Clippers, files, or personal grooming items
Blood Transfusions Tattoos   Used Tooth Brush  
Donate Blood   Handled bloody equipment, guns, rags Had an STD
Tissue Transplant GYN Examination Endoscope Examination
Kidney/Blood Dialyses Ear Nose & Throat Examination Colonoscope  Examination
Military Service Record

Boot Camp & Military Service Information
  Boot Camp
Other
(Command, Platoon, unit, area)
City
State   
Month/Year entered boot camp     
         

2 Duty Station

 Duty Stations  Name/NickName
(Command, Platoon, unit, area)
City
State   
Month/ Year assigned          
Country

3 Duty Station
  Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   
Month/Year assigned   
Country

4 Duty Station

 Duty Stations Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned   
Country

 5 Duty Station
Duty Stations Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned       
Country

6 Duty Station
 Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State
Month/Year assigned  
Country

7 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned  
Country

8 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned  
Country

 9 Duty Station
  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned  
Country
10 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned       
Country
11 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned       
Country
12 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State  
Month/Year assigned       
Country